Provider Demographics
NPI:1861598765
Name:STASNEY, KRAIG MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:KRAIG
Middle Name:MICHAEL
Last Name:STASNEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 HIGHWAY 11 S STE B
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5310
Mailing Address - Country:US
Mailing Address - Phone:601-799-0707
Mailing Address - Fax:601-799-0700
Practice Address - Street 1:718 HIGHWAY 11 S STE B
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5310
Practice Address - Country:US
Practice Address - Phone:601-799-0707
Practice Address - Fax:601-799-0700
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880072Medicaid
MS753195132OtherTAX ID
MS753195132OtherTAX ID
MSU59479Medicare UPIN